Case Snapshot

A 54-year-old woman presented to a virtual clinic describing “burning in the upper stomach,” fatigue, poor sleep, and shortness of breath when walking uphill.

She had spent months attributing it to:
• Stress
• Menopause
• Acid reflux
• Weight gain
• Aging

She was still working full-time, caring for her family, and pushing through her symptoms.

Her cardiovascular risk factors included:
• Hypertension
• Elevated LDL-C
• History of gestational diabetes
• Strong family history of premature coronary disease

An initial workup elsewhere had been reassuring:
• Normal resting ECG
• Normal troponin
• Mildly elevated blood pressure

But something about the story did not fit. She described a noticeable decline in exercise tolerance over the previous six months. Further evaluation showed evidence of ischemia, and coronary imaging ultimately revealed obstructive coronary artery disease involving the LAD. After initiation of guideline-directed therapy and revascularization, her symptoms significantly improved.

The important part of this case is not just the diagnosis. It is how easy it would have been to miss. Heart disease in women often presents differently than many of us were taught.

Women may present with:
• Fatigue
• Dyspnea
• Indigestion or epigastric discomfort
• Nausea
• Neck, jaw, or back discomfort
• Reduced exercise capacity
• Sleep disturbance
• Anxiety-like symptoms

Many women normalize these symptoms, especially during the menopausal transition, when physiologic changes, stress, hormonal shifts, and competing responsibilities can blur the clinical picture.

Menopause is also an important cardiovascular inflection point. As estrogen levels decline, women often experience worsening cardiometabolic risk, including symptoms of:
• Increased visceral adiposity
• Rising blood pressure
• Insulin resistance
• Adverse lipid changes
• Higher rates of endothelial dysfunction and inflammation

Yet cardiovascular disease remains underrecognized in women, despite being the leading cause of death among women worldwide.

One of the biggest challenges is that women are frequently told they are “fine” because:
• Their symptoms are atypical
• They do not fit traditional risk stereotypes
• Initial testing may appear reassuring

Listening carefully matters. Sometimes the most important finding is a patient telling you: “This is not normal for me.”

Heart disease in women deserves earlier recognition, better awareness, and more nuanced conversations, especially during midlife and menopause.

Case Snapshot

A middle-aged woman presented to a virtual clinic with progressive shortness of breath and tachycardia.

At first glance, it would have been easy to attribute her symptoms to something more benign such as anxiety, deconditioning, or even a viral illness. But something felt off.

She appeared visibly uncomfortable.
Her heart rate was persistently elevated.
Her breathing appeared labored, even at rest.

No dramatic symptoms such as chest pain or collapse. She didn’t have a classic “textbook” presentation.

But her vitals and overall appearance did not match a reassuring story.

She was sent directly to the emergency department.

Further evaluation revealed the diagnosis:
Bilateral pulmonary embolism.

Diagnostic Lessons

Pulmonary embolism is one of those diagnoses that often hides in plain sight.

We’re taught to look for the classic features, sudden pleuritic chest pain, hemoptysis, acute dyspnea. But many patients, particularly women, present more subtly, with progressive shortness of breath, fatigue, or otherwise unexplained tachycardia. 

In this case, the most important clue was persistent tachycardia without a clear explanation. That’s not a benign abnormality. It’s a physiologic signal that something deeper may be wrong, and it should always prompt a pause before reassurance.

Equally important was how the patient looked. Even without a dramatic history, she appeared unwell. There is real value in clinical gestalt here. When a patient’s appearance and vitals don’t align with a reassuring narrative, that mismatch matters.

This is where pulmonary embolism is often missed. Not because we don’t know the diagnosis, but because it doesn’t always present dramatically. Many cases evolve over hours to days, not minutes, which can create a false sense of safety.

Risk stratification tools like Wells criteria and D-dimer can be helpful, but they are adjuncts, not replacements. Clinical judgment still sits at the center of decision-making, especially in outpatient settings where the threshold to escalate can feel less defined.

In this case, the decision to send her to the emergency department was not based on diagnostic certainty — it was based on clinical concern. And that distinction matters. Early escalation, even when the diagnosis isn’t confirmed, can be life-saving.

Clinical Takeaways

Pulmonary embolism remains a leading cause of preventable morbidity and mortality, and missed diagnoses are often tied to atypical or downplayed presentations.

This case serves as a reminder that:

And when something feels off, it’s worth acting on it

Not all high-risk pathology announces itself clearly

Unexplained tachycardia deserves respect

In this month’s PulsePoints case with Ambreen Mohamed, MD, FACC, a 52-year-old man came in with three weeks of chest pressure during exertion that was worse when climbing stairs, but relieved with rest.

He had multiple risk factors, but no prior cardiac diagnosis, and wasn’t on a statin. His ECG and troponin were normal, yet his symptoms pointed to an intermediate likelihood of coronary artery disease.

Instead of a traditional stress test, we chose Coronary CT Angiography (CTA) to look directly at plaque, not just infer ischemia. Results showed a 60–70% narrowing in the proximal LAD with high-risk plaque features, plus additional non-obstructive disease. FFR confirmed a significant lesion, and he underwent PCI with a drug-eluting stent.

With guideline-directed therapy, including a high-intensity statin, aspirin, and a P2Y12 inhibitor, his symptoms resolved and his functional capacity improved.

The bigger takeaway is that Coronary Disease often develops silently, long before a major event, and there is a real opportunity to detect it earlier and prevent it altogether.

For many of our highest risk patients, especially those with premature disease, we should be asking: Are we satisfied with “better” or are we aiming for optimal?

In this PulsePoints case with Ambreen Mohamed, MD, FACC, a 49-year-old South Asian male came to us after a premature NSTEMI. He had diabetes, a strong family history of early heart disease, and a baseline LDL of 162 mg/dL.

We started high-intensity statin therapy and ezetimibe, alongside lifestyle changes, and his LDL came down to 82 mg/dL.

By older standards, this is a sufficient decrease, but by current secondary prevention standards and when aiming for optimal, it falls short.
Given high-risk status, our LDL goal was below 55 mg/dL. So, we added a PCSK9 inhibitor evolocumab. 12 weeks later, his LDL dropped to 28 mg/dL, with no side effects, causing the patient to feel empowered.

PCSK9 inhibitors are an optimal solution because they are a protein that binds LDL receptors in the liver and marks them for destruction, delivering 50 to 60% additional LDL reduction on top of statins.

High-intensity statin plus ezetimibe is not the ceiling in very high-risk patients. If LDL remains above goal, PCSK9 inhibitors are not extreme. They are evidence-based. The combination of aggressive lipid lowering and lifestyle intervention is powerful, especially in populations at high risk.

Uncontrolled hypertension is a major contributor to preventable cardiovascular events, and Black communities are disproportionately affected.

This month’s PulsePoints case with Dr. Ambreen Mohamed, MD, FACC follows a middle-aged African American man with long-standing, poorly controlled hypertension — placing him at high risk for stroke, heart failure, and kidney disease.

Using a step-by-step, patient-centered approach, the care team:
✅ Optimized medication selection and dosing
✅ Addressed adherence and side effects
✅ Focused on sodium reduction, sleep, stress, and physical activity
✅ Emphasized consistent home blood pressure monitoring

By taking these steps, his numbers gradually decreased and he reached his target blood pressure.

During Black History Month, this case is a reminder that equity in cardiovascular care is not just about awareness, it’s about action – listening closely, individualizing treatment, and ensuring every patient has the necessary tools and support to succeed.